The feasibility of thoracoscopic-guided intercostal nerve block during uniportal video-assisted thoracoscopic lobectomy of the lung.

Background: Uniportal thoracoscopic surgery has become widely accepted for its favourable outcomes with regard to pain. However, post-operative pain is still a concern associated with thoracic surgery. The objective of this study was to evaluate the post-operative pain of patients undergoing uniportal video-assisted thoracoscopic surgery (VATS) lobectomies using an intra-operative intercostal nerve block. Methods: All consecutive patients undergoing uniportal VATS lobectomies between October 2018 and October 2019 were reviewed retrospectively. Twenty consecutive patients in Group A underwent uniportal VATS lobectomies without intra-operative intercostal nerve blocks. The other 20 consecutive patients in Group B underwent uniportal VATS lobectomies with intra-operative intercostal nerve blocks. Numeric Pain Rating Scale (NRS) scores were recorded at 1, 12 and 24 h postoperatively. The number of anti-inflammatory drugs (non-steroidal anti-inflammatory drug [NSAIDs]) consumed until the time of chest tube removal was also recorded. Results: There was no difference between the groups with regard to sex, age, chest tube duration, length of stay, operative time or laterality. There was a significant difference in post-operative NRS scores at 1 h (P < 0.001) and 12 h (P = 0.014) between the groups. The NSAID consumption was significantly lower in Group B than in Group A (P = 0.038). Conclusion: Intra-operative intercostal nerve blocks with bupivacaine provided immediate post-operative pain relief and reduced post-operative opioid consumption in patients who underwent uniportal VATS lobectomies.

The Learning Curves of Uniportal Video-Assisted Thoracoscopic Surgery Lobectomy: A Single Center Experience.

Backgrounds: The aim of our study is to describe the learning curve for uniportal video-assisted thoracoscopic surgery (VATS) lobectomy from our single center's experience for adopting it because uniportal VATS is generally considered a technically difficult procedure. Methods: A retrospective review of all 164 consecutive patients who underwent uniportal VATS lobectomy between June 2015 and February 2020 was done. A cumulative summation (CUSUM) method was applied to evaluate the learning curves of the operation time. Results: Among the 164 patients, the CUSUM value inflected at the 31st case. Ninety-five consecutive patients underwent uniportal VATS upper lobectomy. The other 69 consecutive patients underwent uniportal VATS lower lobectomy. The operation time CUSUM learning curve analysis revealed that the curves descended from the 21st case in upper lobectomy group and the 12th case in lower lobectomy group. Conclusion: Operators are required to experience at least 21 cases for upper lobectomy and 12 cases for lower lobectomy until the operation time is stabilized.

Subxiphoid single-port thymectomy: six-year experience of a single center.

BACKGROUND: The subxiphoid single-port approach for thymectomy has several advantages compared with conventional lateral transthoracic approaches. However, perioperative outcomes of subxiphoid single-port thymectomy are still lacking. The objective of this study is to present our 6-year experience of subxiphoid single-port thymectomy, including our learning curve. METHODS: All consecutive 49 patients undergoing subxiphoid single-port thymectomy between August 2014 and September 2020 were reviewed retrospectively. RESULTS: We analyzed data of 49 patients (27 males and 22 females) with a median age of 58 years (range 49-68). Two patients presented postoperative complications. The conversion to a different approach was required in four cases. The median follow-up time was 17 months (range 3-35) and locoregional recurrence was observed in one patient. There were no intraoperative deaths and postoperative mortality. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 24th case. CONCLUSIONS: The subxiphoid single-port approach for thymectomy is a safe and feasible modality with few complications.

Successful Repair of Bronchoesophageal Fistula Through Uniportal Video-Assisted Thoracoscopic Surgery.

This report describes a case of successful repair of bronchoesophageal fistula through uniportal video-assisted thoracoscopic surgery. A 79-year-old female patient presented with persistent cough and aspiration pneumonia. Chest computed tomography and esophagography showed a bronchoesophageal fistula at right side wall of mid to lower esophagus. Esophagogastroduodenoscopy confirmed a fistula in the esophageal diverticulum. Surgical treatment was planned. The operation was performed through uniportal video-assisted thoracoscopic surgery. The patient was discharged 6 days postoperatively without any complication. No recurrence has been observed during 3 months follow-up in the outpatient clinic to date.

Cardiac tamponade due to ruptured cystic teratoma: report of two cases.

We report the rare two cases of cardiac tamponade due to ruptured cystic teratoma. In both cases, a chest computed tomography scan showed large cystic mass with large amount of pericardial effusion. Transthoracic echocardiogram revealed cardiac tamponade physiology. En bloc resection of the mass was performed and pathologic examination showed mature cystic teratoma. The postoperative course of patients was uneventful. A cystic mediastinal teratoma should be considered in the differential diagnosis of pericardial effusion.

Multiple small bowel metastasis of primary non-small cell lung cancer.

Gastrointestinal metastasis could be considered in the differential diagnosis of melena in the patient with NSCLC history.

Large infected pulmonary cyst mimicking empyema thoracis.

Infected pulmonary cyst could be misdiagnosed as empyema thoracis. Here, we report an infected pulmonary cyst in a middle-aged male patient. This report could serve as a reminder for differential diagnosis of infected pulmonary cyst, for which surgical approach would be more safe and effective method.

Large pulmonary sclerosing pneumocytoma in a young female: A rare lung tumor.

We report a case of a 28-year-old female who presented with a solid mass lesion in the right middle lobe (RML). A chest computed tomography (CT) scan showed a 3.5 cm sized round and solid mass between the medial and lateral segment of the RML. The patient underwent a percutaneous lung biopsy with CT scan guidance and pathological examination showed pulmonary sclerosing pneumocytoma. RML lobectomy was performed for definitive treatment. Here, we describe this rare lung disease which presented as a large homogeneous lesion. Pulmonary sclerosing pneumocytoma should be considered in the differential diagnosis of solitary lung tumor, even if the patient is young.

Primary pulmonary diffuse large B-cell lymphoma in a young female patient.

Even if the patient is young or female, a primary pulmonary diffuse large B-cell lymphoma could be considered as a differential diagnosis of multifocal consolidation in the lung.

Primary Pulmonary Undifferentiated Pleomorphic Sarcoma: A Rare Malignant Lung Tumor.

We report a case of a 56-year-old man with persistent right upper lobe cavitary mass. A chest computed tomography scan showed about 4-cm-sized mass with internal low attenuation and peripheral enhancement in right upper lobe apical segment. The lesion size increased over 1 month. Right upper lobectomy was performed with the intention to treat the lesion. Pathological examination showed primary pulmonary undifferentiated pleomorphic sarcoma. We describe this rare lung disease to remind that primary pulmonary undifferentiated pleomorphic sarcoma could be the differential diagnosis of pulmonary cavitary mass lesions.

Single center experience of uniportal VATS anatomical lung resections: Mid-term oncological outcomes.

BACKGROUND: Uniportal video-assisted thoracoscopic surgery (VATS) anatomical lung resection has become widely accepted for its favorable outcomes with regard to pain. However, oncological outcomes, especially mid- or long-term outcomes, are still lacking. The objective of this study was to present our eight-year experience of uniportal VATS anatomical lung resection, including mid-term oncological outcomes. METHODS: All consecutive patients undergoing uniportal VATS anatomical lung resection between June 2012 and February 2020 were reviewed retrospectively. RESULTS: We analyzed data of 170 patients (100 male and 70 female), with a median age of 67 years. The median follow-up time was 21 months (range 11-41). The DFS of the entire cohort was 66.3 months. Stage-correlated DFS was 73.1 months for stage I, 42.6 months for stage II, 30.6 months for stage III and 12.5 months for stage IV. The OS of the entire court was 67 months. Stage-correlated OS was 75.6 months for stage I, 50.2 months for stage II, 31.7 months for stage III and 12.5 months for stage IV. CONCLUSIONS: Uniportal VATS anatomical lung resection for lung cancer can be performed with satisfactory mid-term histology- and stage-related outcomes, which is consistent with prior results of traditional VATS or thoracotomy.

Surgical treatment of micronodular thymoma with lymphoid stroma.

This case was about a 71-year-old man presented to our clinic for an anterior mediastinal mass found on routine chest computed tomography (CT). CT scan showed a lobulating contoured mass in the anterior mediastinum. A preliminary diagnosis was thymoma. The patient underwent subxiphoid uniportal video-assisted thoracoscopic surgery for the extended thymectomy and complete excision of the tumour. The pathological examination showed a micronodular thymoma with lymphoid stroma (MTWLS). In conclusion, this report described an extremely rare tumour, MTWLS, and MTWLS might be considered in the differential diagnosis of mediastinal tumour, especially thymoma.

Isolated unilateral pulmonary artery agenesis presenting with massive hemoptysis.

This case was about a 21-year-old man with recurrent and persistent hemoptysis. Chest computed tomography scan showed a right-sided pulmonary artery agenesis and associated hypertrophic change of right side bronchial arteries. Thoracic aortogram revealed abnormal collateral arteries supplying the right lung. Minor hemoptysis continued even after endovascular embolization of collateral vessels was performed. Right pneumonectomy was performed and the patient was treated successfully. Physicians should be aware that unilateral pulmonary artery agenesis could be a source of hemoptysis and pneumonectomy may be the best treatment.

Mediastinal venolymphatic malformations mimicking thymic carcinoma.

This report was about a 60-year-old asymptomatic female patient who presented to our clinic with an anterior mediastinal mass found on routine chest computed tomography (CT). Chest CT revealed an irregular poorly enhanced anterior mediastinal mass which showed signs of infiltration to adjacent structures with sparse calcifications. The preliminary diagnosis was thymic carcinoma. The patient underwent extended thymectomy via median sternotomy and complete excision of the tumor. A small draining vein to the left brachiocephalic vein and phleboliths were identified in the tumor. A definitive diagnosis was made of mediastinal venolymphatic malformation (VLM). The patient had an uneventful clinical course and was discharged without further complication. This report highlights that it is possible to misdiagnose mediastinal VLM as thymic carcinoma and could serve as a useful reminder to physicians in the future.

Successful sleeve resection of bronchial carcinoid under veno-venous ECMO.

Here, we report a case of a bronchial tumor in the proximal left mainstem bronchus in a 19-year-old male. Diagnosis of the tumor was typical carcinoid, which was established by bronchoscopic biopsy preoperatively. Under femoral veno-venous extracorporeal membrane oxygenation (ECMO), the patient underwent left mainstem bronchus sleeve resection through median sternotomy. The surgical resection margins were confirmed to be tumor-free on frozen section and all lymph nodes were free of tumor. This report describes a carcinoid in the proximal mainstem bronchus which was successfully resected without lobectomy or pneumonectomy and concludes that sleeve resection under extracorporeal membrane oxygenation should be considered in the surgical treatment of mainstem bronchial carcinoid.

Placental transmogrification of the lung presenting as a consolidative lesion with bronchiectasis.

We report a case of a 37-year-old man with a persistent consolidative lesion in the right lower lobe. A chest computed tomography scan showed a 2 cm focal consolidative lesion in the lateral basal segment of the right lower lobe. The size of lesion had slightly increased over four months. Wedge resection of the right lower lobe was performed with the intention to diagnose the lesion. Pathological examination showed placental transmogrification of the lung. We describe this rare lung disease, which presented with the unusual radiologic findings of a consolidative lesion. Placental transmogrification of the lung should be considered in the differential diagnosis of pulmonary consolidative lesions.

A Prospective Randomized Trial Comparing Manual Needle Aspiration to Closed Thoracostomy as an Initial Treatment for the First Episode of Primary Spontaneous Pneumothorax.

BACKGROUND: Variation exists in the initial treatment for the first episode of primary spontaneous pneumothorax (PSP), and no definitive consensus exists due to a lack of high-quality evidence. This study examined the outcomes of needle aspiration and closed thoracostomy in first episodes of PSP requiring intervention. METHODS: This study was a randomized, prospective, single-center trial conducted between December 2015 and August 2016. Patients of all ages with a documented first episode of PSP who were unilaterally affected, hemodynamically stable, and had a pneumothorax measuring over 25% in size were included. Patients with underlying lung disease, severe comorbidities, bilateral pneumothorax, tension pneumothorax, recurrent pneumothorax, traumatic pneumothorax, and pregnancy were excluded. Patients were randomly assigned to the needle aspiration or closed thoracostomy group using a random number table. RESULTS: Forty patients with a first episode of PSP were recruited, and 21 and 19 patients were included in the needle aspiration group and the closed thoracostomy group, respectively. The hospital stay of each group was 2.1±1.8 days and 5.4±3.6 days, respectively (p<0.01). However, no significant differences were found in the success rate of initial treatment or the 1-month and 1-year recurrence rates. CONCLUSION: Needle aspiration is a favorable initial treatment in patients experiencing a first episode of PSP.

Surgical Repair of Aortocaval Fistula Presenting with Cardiogenic Shock.

Aortocaval fistula (ACF) occurs in <1% of all abdominal aortic aneurysms (AAAs), and in 3% to 7% of all ruptured AAAs. The triad of clinical findings of AAA with ACF are abdominal pain, abdominal machinery bruit, and a pulsating abdominal mass. Other findings include pelvic venous hypertension (hematuria, oliguria, scrotal edema), lower-limb edema with or without arterial insufficiency or venous thrombus, shock, congestive heart failure, and cardiac arrest. Surgery is the main treatment modality. We report successful surgical treatment in a patient with a ruptured AAA with ACF who presented with cardiogenic shock.

A New Root-Strengthening Technique for Acute Aortic Dissection with a Weakened Aortic Root: The Neo-Adventitia Technique.

BACKGROUND: Dissection flaps in acute type A aortic dissection typically extend into the root, most frequently into the non-coronary sinus (NCS). The weakened root can be susceptible not only to surgical trauma, but also to future dilatation because of its thinner layers. Herein, we describe a new technique that we named the "neo-adventitia" technique to strengthen the weakened aortic root. METHODS: From 2012 to 2016, 27 patients with acute type A aortic dissection underwent supracommissural graft replacement using our neo-adventitia technique. After we applied biologic glue between the dissected layers, we wrapped the entire NCS and the partial left and right coronary sinuses on the outside using a rectangular Dacron tube graft that served as neo-adventitia to reinforce the dissected weakened wall. Then, fixation with subannular stitches stabilized the annulus of the NCS. RESULTS: There were 4 cases of operative mortality, but all survivors were discharged with aortic regurgitation (AR) classified as mild or less. Follow-up echocardiograms were performed in 10 patients. Of these, 9 showed mild or less AR, and 1 had moderate AR without root dilatation. There were no significant differences in the size of the aortic annulus (p=0.57) or root (p=0.10) between before discharge and the last follow-up echocardiograms, and no reoperations on the aortic roots were required during the follow-up period. CONCLUSION: This technique is easy and efficient for reinforcing and stabilizing weakened roots. Furthermore, this technique may be an alternative for restoring and maintaining the geometry of the aortic root. An externally reinforced NCS could be expected to resist future dilatation.